Post on 05-Jun-2018
Copyright © 2016 Studer Group. Please do not quote or disseminate without Studer Group authorization
Using HCAHPS Survey Custom Questions to
Drive Staff Engagement
Diana Topjian, RN, MSN, D.M., C-ENP
Account Lead/Coach
Studer Group
Copyright © 2016 Studer Group. Please do not quote or disseminate without Studer Group authorization
• Verbalize the value of adding HCAHPS custom questions to the
survey to deepen staff engagement
• Describe how to use the results from custom HCAHPS to engage
staff
• Develop a plan to implement the custom questions in your
organization
2
Outcome Goals
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Execution Framework: Evidence-Based LeadershipSM
3
LEADER EVALUATIONImplement an organization-wide
leadership evaluation system to
hardwire objective accountability
LEADER DEVELOPMENTCreate process to assist leaders in
developing skills and leadership
competencies necessary to attain
desired results
MUST HAVES®
Rounding, Thank You Notes, Employee
Selection, Pre and Post Phone Calls, Key
Words at Key Times
PERFORMANCE GAPRe-recruit high and middle performers,
Move low performers up or out
STANDARDIZATIONAgendas by pillar, peer interviewing, 30/90 day
sessions, pillar goals
ACCELERATORSLeader Evaluation Manager®
Validation MatrixSM
Provider Feedback SystemSM
Studer Group Rounding
Patient Call ManagerTM
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Change
Heath
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• Hourly Rounding®
• Bedside Shift Report
• Nurse Leader Rounding
• Post Discharge Calls
5
Focused Behaviors and Tactics: Direct the Rider
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Connecting Heart and Mind
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Randy Johnson BA
Director of Marketing
THE HEART HOSPITAL Baylor Plano
Copyright © 2016 Studer Group. Please do not quote or disseminate without Studer Group authorization
Did you know? If 99% is good enough, then:
• 12 newborns will be given to the wrong parents daily.
• 103,260 income tax returns will be processed incorrectly this
year.
• Two plane landings daily at O' Hare International Airport in
Chicago will be unsafe.
• 18,322 pieces of mail will be mishandled in the next hour.
• 291 pacemaker operations will be performed incorrectly this
year.
• 20,000 incorrect drug prescriptions will be written in the next 12
months
Copyright © 2016 Studer Group. Please do not quote or disseminate without Studer Group authorization
Did you know? If 99% is good enough, then:
• 107 incorrect medical procedures will be performed by the end of
the day today.
• 2,000,000 documents will be lost by the IRS this year.
• 22,000 checks will be deducted from the wrong bank accounts in
the next 60 minutes.
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Finding Meaning through Data
Up to Date
Connects to
Actions
Understandable
Meaningful
Copyright © 2016 Studer Group. Please do not quote or disseminate without Studer Group authorization11
Q4 FY ‘15
(Jul 1 –Aug 17)
Current Quarter
n=39
Q3 FY ‘15
(Apr – Jun)
Prior Quarter
n=127
Q2 FY ‘15
(Jan - Mar)
n=128
Q1 FY ‘15
(Oct - Dec)
n=123
FY ‘15
YTD
n=417
FY ‘14
YTD
n=428
Overall Rating of Care 38% 69% 76% 28% 54% 88%
Communication with Nurses 78% 99% 86% 88% 95% 93%
Nurses treat with courtesy/respect 90% 99% 49% 91% 90% 85%
Nurses listen carefully to you 56% 99% 91% 75% 89% 97%
Nurses expl in way you understand 80% 99% 95% 92% 98% 83%
Communication with Doctors 49% 97% 46% 73% 73% 87%
Doctors treat with courtesy/respect 84% 97% 62% 62% 82% 86%
Doctors listen carefully to you 76% 96% 67% 87% 83% 92%
Doctors expl in way you understand 8% 96% 20% 63% 55% 78%
Responsiveness of Staff 11% 84% 76% 60% 64% 81%
Call button help soon as wanted it 25% 83% 80% 66% 69% 83%
Help toileting soon as you wanted 6% 79% 66% 53% 59% 76%
Pain Management 34% 83% 70% 60% 67% 86%
Pain well controlled 7% 73% 70% 51% 58% 65%
Staff do everything help with pain 80% 87% 64% 66% 75% 95%
Communication re Medication 15% 93% 73% 80% 74% 94%
Tell you what new medicine was for 47% 89% 56% 41% 59% 93%
Hospital Environment 74% 98% 95% 86% 92% 92%
Cleanliness of hospital environment 97% 92% 87% 71% 86% 87%
Quietness of hospital environment 38% 97% 93% 87% 89% 90%
Discharge Information 88% 89% 48% 68% 70% 81%
Staff talk about help when you left 90% 85% 42% 72% 66% 75%
Info re symptoms/prob to look for 78% 87% 57% 58% 66% 79%
Transition of Care 46% 92% 36% 70% 65% 70%
Hosp staff took pref into account 50% 95% 59% 59% 73% 80%
Good understanding managing health 43% 87% 27% 55% 55% 60%
Understood purpose of taking meds 40% 96% 19% 72% 62% 60%
HCAHPS (Overall) - Goal - > 80th percentile in 6 of the composites
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Action Plan:
12
Communication with Nurses Bedside Shift Report (to include Patient Communication
Board)
Communication with Doctors
Responsiveness of Staff Purposeful Hourly Rounding
Pain Management Establishing a pain goal and managing expectations
Communication re Medication
Hospital Environment
Discharge Information
Transition of Care
Source: Hospital System in the SE
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Key Focus Questions for Comparisons:
1.
2.
3.
4.
13
Using Data to Connect the Heart and Mind: HCAHPS
HCAHPS Custom Questions Y/N/Unsure
How often did nursing staff come into your room to check or round on you
during the day? Would you say every hour, every two hours, every few hours,
or a couple of times a day?
Did a nurse leader visit you during your stay?
After discharge, did you receive a phone call from a hospital staff member
regarding your recovery at home?
At shift change, did the nurses include you in their conversation regarding your
plan of care?
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8895
1 10
102030405060708090
100
1Q15 2Q15
Did a staff member visit you hourly?
YES NO
n=131 n=49 n=174 n=42
HCAHPS Overall Rating
*Data pulled from Press Ganey by discharge date 7.16.15
**Percentile rankings based on 3Q13-2Q14 CMS results
***Major SE System
Pe
rce
ntile
Ra
nk
Average increase in %ile ranking when
answered yes to staff member visit
91%
Copyright © 2016 Studer Group. Please do not quote or disseminate without Studer Group authorization15
73
1
84
1
73
2
79
21
35
1
88
9
89
1
78
2
88
4
0
10
20
30
40
50
60
70
80
90
100
YES NO
Did a Nurse Leader visit you during your stay?
Overall Hospital Rating
Comm. With Nurses
Response of Hosp. Staff
Comm. With Doctors
Hosp. Environment
Pain Management
Comm. about Medicines
Discharge info
Care Transistions
Carolina East
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*Data pulled from Press Ganey by discharge date
2.16.16
Date Range Oct. 1, 2015- to date
85.1 81.388.4
94.6
78.7 82.574.9
95.2 95.2
67
42.9
57.1 57.1 57.146.4 41.7
25
73.1 73.1
34.5
0102030405060708090
100
Did a nurse manager from patient care visit?
YES NO
N=
49 N=
31
N=5N=10
6
N=
7
HCAHPS Custom Question: Greenville Hillcrest
Correlation with Nurse Leader visit
N=24
3
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HCAHPS Custom Questions: Rutland Regional Medical Center
17
NLR-Nurse Leader Rounding
PDC-Post discharge call
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Impact to HCAHPS:
Transition of Care Call Received vs. Not Received
0
10
20
30
40
50
60
70
80
90
100
How often did hospital staffdescribe possible side effects
in a way you couldunderstand?
How often did the hospitalstaff tell you what the
medicine was for?
Did the MDs, Nurses, or otherhospital staff talk with youabout whether you would
have the help needed whenyou left the hospital?
Received Call No Call
Source: Major Hospital in SE region
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82
1
94
1
84
1
88
1
49
1
90
1
95
1
87
1
91
1
0
10
20
30
40
50
60
70
80
90
100
YES NO
Leader Round and PCM Call
Overall Hospital Rating
Comm. With Nurses
Response of Hosp. Staff
Comm. With Doctors
Hosp. Environment
Pain Management
Comm. about Medicines
Discharge info
Care Transistions
Carolina East
Copyright © 2016 Studer Group. Please do not quote or disseminate without Studer Group authorization
• Verbalize the value of adding HCAHPS custom questions to the
survey to deepen staff engagement
• Demonstration of correlation of behavior to patient’s experience
• Develop a plan to implement the custom questions in your
organization
• Identify key words
• Determine tactic(s) to use (usually those you are struggling to
hardwire)
• Discuss with vendor
• Describe how to use the results from custom HCAHPS to engage
staff
• Huddles, staff meeting, posted on pillar board; connect the
action to the outcome and the difference one person can make
21
Outcome Goals
Copyright © 2016 Studer Group. Please do not quote or disseminate without Studer Group authorization22
“Always bring it back to values..."
— Quint Studer
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Change
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EVALUATION REMINDER:
We want your feedback to get better. Please
remember to take the session evaluation. Thank you!
Diana Topjian, RN, MSN, D.M., C-ENP
Account Lead/Coach
Diana.Topjian@studergroup.com
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